ATI RN
ATI Capstone Comprehensive Assessment B
1. What intervention should the nurse implement for a patient receiving a blood transfusion?
- A. Administer antihistamines to prevent allergic reactions.
- B. Monitor the patient for signs of circulatory overload.
- C. Ensure the blood transfusion is completed within 4 hours.
- D. Check the patient's vital signs every 30 minutes during the transfusion.
Correct answer: B
Rationale: The correct intervention for a patient receiving a blood transfusion is to monitor the patient for signs of circulatory overload. This is crucial to prevent fluid overload, which can lead to serious complications. Administering antihistamines is not a routine intervention during blood transfusions unless the patient shows signs of an allergic reaction. Ensuring the completion of the blood transfusion within a specific time frame is not as critical as monitoring for circulatory overload. Checking vital signs every 30 minutes is essential, but the specific focus should be on monitoring for signs of circulatory overload.
2. A nurse is preparing to administer a blood transfusion. What is the most important action to ensure patient safety?
- A. Check the patient's vital signs every 15 minutes during the transfusion.
- B. Verify the patient's identity with two identifiers before starting the transfusion.
- C. Ensure the blood product is administered within 4 hours of removal from the blood bank.
- D. Ensure the patient has signed the informed consent form.
Correct answer: B
Rationale: The most important action to ensure patient safety when administering a blood transfusion is to verify the patient's identity with two identifiers before starting the transfusion. This step is crucial to prevent transfusion errors, such as giving the blood to the wrong patient. Checking vital signs, ensuring timely administration, and confirming informed consent are also important aspects of blood transfusion safety but verifying the patient's identity is the highest priority to prevent errors.
3. A client is preparing for a surgical procedure but refuses to remove religious jewelry. What is the best course of action?
- A. Proceed with surgery and document the refusal.
- B. Ask the client for permission to secure the jewelry.
- C. Remove the jewelry and store it safely.
- D. Postpone the surgery until the jewelry is removed.
Correct answer: B
Rationale: The best course of action is to ask the client for permission to secure the jewelry. This respects the client's religious beliefs while also ensuring that the jewelry does not interfere during the surgical procedure. Proceeding with surgery without addressing the presence of the jewelry can lead to complications or distress for the client. Removing the jewelry without consent or postponing the surgery solely due to the presence of religious jewelry are not appropriate actions in this situation.
4. What is the most important nursing intervention for a patient with diarrhea?
- A. Encourage the patient to increase fluid intake.
- B. Monitor the patient's skin integrity.
- C. Check the patient's electrolyte levels.
- D. Educate the patient about infection control measures.
Correct answer: B
Rationale: The correct answer is to monitor the patient's skin integrity. This is crucial because diarrhea can lead to skin breakdown due to frequent bowel movements and increased moisture in the perineal area. By monitoring skin integrity, nurses can prevent skin breakdown, infection, and other associated issues. Encouraging fluid intake (Choice A) is important but not the most critical intervention. Checking electrolyte levels (Choice C) is essential but may not be the top priority at the onset. Educating the patient about infection control (Choice D) is important but secondary to preventing skin breakdown in a patient with diarrhea.
5. If a nurse is uncomfortable documenting a verbal prescription, what should the nurse do?
- A. Document the prescription without seeking clarification.
- B. Clarify the verbal prescription with the healthcare provider.
- C. Refuse to document the prescription.
- D. Speak with the client's family to clarify the situation.
Correct answer: B
Rationale: When a nurse is uncomfortable documenting a verbal prescription, the best course of action is to clarify the prescription with the healthcare provider. This is crucial to ensure that the information is accurate and to provide safe and appropriate care. Option A is incorrect because blindly documenting without seeking clarification can lead to errors. Option C is incorrect as refusing to document the prescription altogether is not in the best interest of the patient. Option D is also incorrect as speaking with the client's family is not the appropriate step to clarify a verbal prescription; the healthcare provider should be the primary source for this clarification.
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